Hi, I've been working on the floor for 6 weeks now and I'm still trying to fine tune my discharge documentation so far it goes something like this:
40yr old male presents to ED with HA, N/V, Chest Pain.
medications taken PTA: pepcid, tylenol
diagnostics performed: CBC, BMP, CK, Trop, ECG, CXR
medications given: Zofran 4mg, Motrin 600mg
Discharge diagnosis: Acute abdominal pain, cephalgia
labs normal, ECG normal, no acute abnormalities on CXR
"DC'd pt from ED c family. AOx4, Respirations even and unlabored, skin pink, warm and dry, ambulatory with steady gait, still c/o pain in abd LUQ 8/10 burning, tolerable, no c/o nausea or HA, NAD, VSS, afebrile. IV DC'd tip intact, dressing applied, pressure held. After care instructions provided and explained. Copies of lab results and ECG provided. Left ED with all belongings."
is there anything else I should include. my preceptor is always saying i need to "paint a picture"